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Treating Adults With Attention-Deficit/Hyperactivity Disorder

Treating Adults With Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is often underappreciated and inadequately treated in adults.1 Long thought to be a disorder of childhood, ADHD is now believed to persist into adulthood in approximately half of all cases.2 Current epidemiological data suggest an estimated prevalence of 4.4% in adults.3 However, this may be an underestimation; a recent study questioned the requirement that symptoms be present before age 7 and suggested that the criteria for age of onset be raised, possibly to 12 years.1 Further research is needed in this area.

The importance of adequately treating ADHD in adults is underscored by evidence of significant impairment secondary to untreated ADHD, including significant deficits in educational, occupational, and social functioning.4 Poor driving skills have been reported in this population and are of particular concern given the increased morbidity and mortality associated with traffic accidents.5,6

By definition, adults have lived with symptoms of ADHD longer and may have a higher degree of sequelae than children. These sequelae include poor self-esteem, temper issues, mood reactivity, anxiety, decreased motivation, and other symptoms associated with depression and anxiety.7 Along these lines, the rates of comorbidity in adult ADHD are striking, with estimates as high as 90%.8 Common comorbidities include disruptive and antisocial behaviors, learning disorders, tic disorders, anxiety disorders, personality disorders, substance abuse disorders, and mood disorders.8 It remains unclear how much comorbidity is the result of adults living with untreated ADHD for many years. Studies suggest that adults with ADHD who have comorbid conditions are often treated for the coexisting disorder but not ADHD, further emphasizing the need for adequate detection and treatment of ADHD.9

Integrated treatment
Although the treatment of ADHD in adults has received little attention—particularly in comparison with the treatment of children and adolescents—some general guiding principals are evident.

First, the importance of integrating psychosocial intervention is underscored.2,10,11 There is strong evidence that core deficits of inattention, hyperactivity, and impulsivity can be treated effectively with standard ADHD medication. However, without adequate psychosocial treatment, the improvement in these core symptoms may not translate into improved functioning.

Children who are typically in a school setting have a built-in system for addressing the deficits inherent with ADHD, but this is not the case with adults and medication may not alleviate all the symptoms of adult ADHD.8 Adults may be particularly good candidates for psychosocial intervention since they are typically self-referred, as opposed to children, who are brought in by their parents.10

Specific psychosocial interventions that hold promise include psychoeducation; behavioral modification; social skills training; academic/occupational intervention; and psychotherapy,2,8 including cognitive-behavioral therapy, which has recently been adapted for the treatment of adults with ADHD.10

All adults who are being treated for ADHD should receive basic psychoeducation regarding the symptoms and course of the disorder.8 The importance of medication compliance should be integrated into the overall treatment plan.12 Furthermore, patients may be referred to various self-help books or support organizations such as Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD).2

Fostering the development of coping skills and helping the patient to better structure his or her environment are also important in the psychosocial treatment of ADHD.8 Cognitive-behavioral therapy in adults with ADHD focuses on improving coping skills that are impaired by many years of distractibility, disorganization, and impulsivity, and holds particular promise as an adjunct to medication; however, controlled trials are needed to confirm efficacy.10

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